Medical Questionnaire before scuba diving by monkey6

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									Medical Questionnaire Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is relatively safe. When established safety procedures are not followed, however, there are increased risks. To scuba dive safely, you should not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with coronary disease, a current cold or congestion, epilepsy, a severe medical problem or who is under the influence of alcohol or drugs should not dive. If you have asthma, heart disease, other chronic medical conditions or you are taking medications on a regular basis, you should consult your doctor and the instructor before participating in any diving programme and on a regular basis thereafter completion. You will also learn from the instructor the important safety rules regarding breathing and equalization while scuba diving. The purpose of this medical questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities. Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. We will supply you with a RSTC Medical Statement and Guidelines for Recreational Scuba Divers Physical Examination to take to your physician. 1. 2. 3. Could you be pregnant, or are you attempting to become pregnant? Are you currently taking prescription medication? (with the exception of birth control or anti-malarial) Are you over 45 years of age and can say YES to any one or more of the following: o Currently smoke a pipe, cigars or cigarettes o Have a high cholesterol level o Have a family history of heart attack or stroke o Are currently receiving medical care o High blood pressure o Diabetes mellitus, even if controlled by diet alone Have you ever had, or do you currently have: o Asthma, or wheezing with breathing or wheezing with exercise? o Frequent or severe attacks of hayfever or allergy? o Frequent colds, sinusitis or bronchitis? o Any form of lung disease? o Pneumothorax (collapsed lung)? o Other chest disease or chest surgery? o Behavioral health, mental or psychological problems (panic attack, fear of closed or open spaces)? o Epilepsy, seizures, convulsions or take medicine to prevent them? o Recurring complicated migraine headaches or take medicine to prevent them? o Blackouts or fainting (full/partial loss of consciousness)? o Frequent or severe suffering from motion sickness (seasick, carsick, etc)? o Dysentery or dehydration requiring medical intervention? o Any dive accidents or decompression sickness? o Inability to perform moderate exercise (eg. Walk 1.6km/one mile within 12 minutes)? o Head injury with loss of consciousness in the past 5 years? o Recurrent back problems? o Back or spinal surgery? o Diabetes? o Back, arm or leg problems following surgery, injury or fracture? o High blood pressure or take medicine to control blood pressure? o Heart disease? o Heart attack? o Angina, heart surgery or blood vessel surgery? o Sinus surgery? o Ear disease or surgery, hearing loss or problems with balance? o Recurrent ear problems? o Bleeding or other blood disorders? o Hernia? o Ulcers or ulcer surgery? o A colostomy or ileostomy? o Recreational drug use or treatment for, or alcoholism in the past 5 years?

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This questionnaire is provided by Aliwal Dive Centre. Contact us on: Phone: +27 (0) 39 973 2233 Fax: +27 (0) : 39 973 2133 Mobile: +27 (0) 82 893 2852 E-mail: dive@aliwalshoal.co.za


								
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